Background

Although he's known as “the PICC guy” around the University of Michigan
Health System, Vineet Chopra, MD, MSc, FACP, appreciates the difficulty many hospitalists
face choosing vascular access devices for their patients. “It's not easy, because
there's no good data. … We have general, very nonspecific recommendations,”
he said during his Hospital Medicine 2017 session “Take Your PICC!”

Choosing an inappropriate device can have serious consequences for patients. For example,
you'd never want to place a PICC with more lumens than necessary because the risk
of bloodstream infection increases with the lumens, Dr. Chopra reported. “If
you look at a single lumen, the rate's about 2%, a double lumen it goes to 3%, a triple
it moves up to almost 4%,” he said.

To help clinicians choose the best device, Dr. Chopra and colleagues developed the
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), a set of recommendations
on vascular access device selection, published by Annals of Internal Medicine on Sept. 15, 2015. (See the October 2015 ACP Hospitalist for more on MAGIC.) Now he's working to get those recommendations from paper into
practice.

How it works

In Michigan, a consortium of 51 hospitals collaborates on a quality improvement (QI)
initiative funded by Blue Cross/Blue Shield and Blue Care Network. “About two
years ago, we started with a pilot that's since morphed led to a full-fledged statewide
project looking at PICC use, outcomes and complications,” said Dr. Chopra.
The project began by gathering data on how vascular devices are used in the participating
facilities and then moved on to developing strategies for bringing care in line with
the MAGIC recommendations.

The strategies varied by hospital. At some hospitals, the solutions were as simple
as a form that helped clinicians choose a PICC or midline. At the University of Michigan,
an order set based on the guidelines was integrated into the electronic health record.
“It basically takes the MAGIC criteria and puts it into Epic. It forces people
to look at the indication for use,” said Dr. Chopra. “If you choose
difficult access [as the indication], the next question is how long you're going to
use it for. If you say less than five days, it will ask you for a clinical reason—why
are you doing that?” The tool also asks about the number of lumens required
and the patient's renal function, among other factors, to help ensure appropriate
use.

Results and challenges

Since the project launched, participating hospitals' practices have come more in line
with the recommendations, Dr. Chopra reported. “They're all different, but
they're all able to do it,” he said.

Across Michigan, the percentage of PICCs that were single-lumen increased from 36.6%
in the second quarter of 2015 to 40.9% in the first quarter of 2016. Meanwhile, triple-lumen
use dropped from 13.5% to 10.0% in the same period. The percentage of PICCs in place
for less than five days (another practice counter to the recommendations) dropped
from 24.0% to 19.0% overall.

PICC complications are also decreasing. “We've seen a drop in our DVT rates
for the first time. We've gone from 3% down to 2%,” said Dr. Chopra. A community
hospital that participated in the initial pilot project showed a 48% drop in occlusion
events and a 32% decrease in venous thromboembolism and central line-associated bloodstream
infections in a year of order-set use.

“We estimate they saved about $600,000 conservatively,” said Dr. Chopra.
“Pretty good for a vascular access nurse-led QI project, right?”

Challenges faced by the program include clinician buy-in, especially in the ICU. The
evidence base isn't very robust, with few meta-analyses or systematic reviews, Dr.
Chopra noted. Hospitals may also lack the resources to modify their electronic medical
record systems.

Next steps

To help such facilities and expand their work outside the state, Dr. Chopra and colleagues
created a website of free resources and more recently, another tool. “There's an app for that,” he said.
The recently released MAGIC app is free for Android and iOS devices and works similarly to the University of Michigan order set, asking questions
about a patient's indications for vascular access and offering guidance on device
selection.

For example, “If you choose IV antibiotics, the next question is, ‘Have
you gained [infectious disease] approval?’ If you are bold enough to say no,
it says, ‘Whoa, stop,’” Dr. Chopra described. He noted that it's
entirely up to the clinician using the app to follow the advice; the researchers are
not tracking the data.

They do plan to follow up with users to see how the app is working or could be improved
and hope to eventually add features for patients. “Wouldn't it be great if
you, as a patient, could ask the right questions before you get the PICC or know how
best to care for your device with videos or instructional diagrams?” Dr. Chopra
said.

Words of wisdom

Although vascular access nurses are natural leaders of projects to improve PICC use,
hospitalists have proven to have a key role in past efforts. “Because physicians
don't like being told no by my colleagues in nursing, they need a physician champion,”
said Dr. Chopra.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.